Basic Prescription

If you are ordering Peptides, Hormones, or any other product that requires a prescription, please complete the form below, as your prescription will ship from a US compounding pharmacy that provides these on a patient-specific basis.

For all controlled substances, we will also require your driver's license information per regulations, which you may submit in this HIPAA compliant form or call us on 1800 BOD-IDEY with the information.

Alternatively, you may choose to register as a new patient in our secure Patient Portal.

First Name and Last Name*

First NameLast Name

Mailing Address (Optional if not entered previously for Semaglutide order)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email*

example@example.com

Phone Number*

Driver's License Number

Needed for Controlled Substances

Date of Birth (Pharmacy Requirement)*

What is your Gender?*

MaleFemale

Check the conditions that apply to you or to any members of your immediate relatives:

Please write the "other" from above in the box below:

Medication Allergies*

Upload your lab work (optional)

Signature*

Prescription Intake Form